Manoeuvring through treatment plans can be challenging for plan members who are both managing a chronic health condition and have been prescribed a specialty biologic drug. Accessing and administering the drug and dealing with layers of approvals and coverage can seem confusing and arduous in the beginning.

By the time a patient receives a prescription for a specialty biologic drug, he or she is likely under the care of a specialist for their chronic health condition as well as their family physician. They have most likely tried a number of other treatment alternatives with varying degrees of success. The drugs they tried before arriving at this new prescription may or may not have required prior authorization from a provincial health program or their insurer. Most of the drugs they’ve likely taken prior have been by mouth and likely did not require special handling or temperature controls.

Read: Drug plan trends in Canada

Most manufacturers of specialty biologics offer patient assistance programs (PAPs) for patients whose treatment plans include the use of specialty drugs. While PAPs can include a financial assistance component for those patients for whom the cost of drug or their co-pay is a barrier to accessing treatment, PAPs include a variety of other mechanisms for patient education and support.

PAPs generally begin the interaction with a new patient by educating them about the drug itself and the process of actually getting the drug and then taking the drug. Most specialty biologic drugs are taken by infusion where the patient receives the drug by intravenous, usually at an infusion clinic or in hospital, or by injection at home, which is an adjustment for many people. The representative from the PAP will also take information from the patient regarding any private drug coverage they have in place, and will often assist with the prior authorization process.

Read: 3 drug trends you need to know

After the drug has been approved for coverage by provincial health where applicable and the patient’s private drug plans and treatment has begun, PAPs can help patients stay compliant to treatment through regular check-ins regarding how the therapy is going and whether they are experiencing any side effects to the drug.

PAPs will also liaise with the prescribing specialist to assist the patient with dosing, and by sequencing treatment around medical tests that are required to monitor patient health while receiving the treatment, or another illness. For example, if the patient has been given antibiotics for bronchitis which they will still be taking when an infusion is scheduled, the PAP nurse can liaise with the patient’s physician to make sure the infusion can go ahead as scheduled, or reschedule the appointment before the biologic drug is dispensed and isn’t able to be used, reducing wastage.

Read: Predictive modelling for your specialty drug spending

When a patient will take their drug by self-injection, PAPs can train the patient or their caregiver about how to give an injection, and provide education about patient safety.

Many insurers have also introduced programs to help support plan members or their dependents who are prescribed specialty drugs. Generally, the prior authorization process flips the switch for these insurer support services. Like PAPs, their primary goal is to improve patient health outcomes. Unlike PAPs, an additional mandate of these insurer programs is to ensure that lower-cost therapies are considered if appropriate for the patient’s condition. As they are not tied to a pharmaceutical manufacturer, they can also assess the appropriateness and effectiveness of the treatment program and recommend alternative therapies from other manufacturers.

Most insurer programs look to integrate with PAPs without duplicating services or creating more work for the plan member. Rather, these two support mechanisms generally look to work together to facilitate access to treatment, coordinating pharmacy set-up within the insurer’s parameters when a preferred provider network or preferred pricing arrangement exists, leveraging financial support for patients and creating a flow of communication around coverage and treatment.

Read: It’s time to rethink prior authorization

When considering the impact of specialty drugs on their drug plan design and experience, plan sponsors can ensure that they select an insurer partner who shares their philosophy of specialty drug support and that their prescription drug program encourages or mandates patients to participate in PAPs when available.

Plan sponsors should ask for details from the insurer about how their prior authorization and specialty drug support mechanisms work, so that they can fully understand the impact on their plan members’ experience. Plan sponsors can also include a link to their insurer’s plan member website on their wellness hub or employee intranet site. Plan members can often contact their insurer for information about the availability of both public reimbursement programs in Canada, and helps them understand the options for coverage for their unique circumstances.

Kim Siddall is a vice-president and local practice leader at Aon. She has more than 20 years of experience in the health and benefits industry. These are the views of the author and not necessarily those of Benefits Canada.
Copyright © 2018 Transcontinental Media G.P. Originally published on

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